Provider Demographics
NPI:1174524888
Name:MIMELES, BOBBY L (MD)
Entity type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:L
Last Name:MIMELES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 S I 10 SERVICE RD W
Mailing Address - Street 2:SUITE 301
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-7404
Mailing Address - Country:US
Mailing Address - Phone:504-885-8225
Mailing Address - Fax:504-885-7642
Practice Address - Street 1:4720 S I 10 SERVICE RD W
Practice Address - Street 2:SUITE 301
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-7404
Practice Address - Country:US
Practice Address - Phone:504-885-8225
Practice Address - Fax:504-885-7642
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2008-01-15
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
LA011441207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00163179OtherMEDICARE RR
LA53107Medicare PIN
LAP00163179OtherMEDICARE RR